Documentation Specialist - FT - Days - Oncology Shared - 21159

DHR Health; Edinburg (TX); On-site; USD 35,000 - 55,000; Full time

Job summary

DHR Health in Edinburg, TX is seeking a Documentation Specialist to support physicians in chart documentation during patient visits and rounds. The role involves accompanying providers, recording observations, and ensuring accuracy in EMR entries.

The ideal candidate has strong Microsoft Office skills, excellent communication, and prior hospital or physician office experience. This full-time position emphasizes patient data integrity and coordination among care teams.

Qualifications

• High School diploma or equivalent required or preferred.
• Proficiency with Microsoft Office suite.
• Strong written and verbal communication skills required.

Responsibilities

• Promotes the facility mission, vision and values in daily duties.
• Keep track of laboratory tests, medications, and radiology tests ordered by the physician.
• Gather data for physician review (laboratory results, reports, medical records).
• Coordinate communication between physicians and staff, and handle phone calls.
• Document consultations between physicians and a patient’s other doctors or staff.
• Take vital signs and prepare patients as needed.
• Accompany provider to hospital to document consults or rounds as needed.
• Provide patients with updates about waits and delays.
• Document all procedures, diagnoses, treatments, and discharge information.
• Perform other duties as assigned.

Skills

Written communication

Verbal communication

Customer service

Attention to detail

Education

High School diploma or equivalent

Tools

EMR system

Microsoft Office

Job description

Documentation Specialist - FT - Days - Oncology Shared - 21159

US:TX:Edinburg | RMF CLINIC | Full Time

Posted yesterday

Description

DHR Health - US:TX:Edinburg - Days

Summary:

POSITION SUMMARY:

The Primary role of a medical Documentation Specialist is to assist the physician with the complete documentation of patients’ charts. Documentation Specialist accompany the physician as he/she examines and interviews patients and then records the physician’s observations and comments on either on paper or in an electronic medical record (EMR) depending on what the practice uses. Documentation Specialist will accompany physician on hospital rounds and consultations if required. All information is recorded in the presence of a physician, as dictated by the physician.

POSITION EDUCATION/QUALIFICATIONS:

• ¨ High School graduate or equivalency is preferred.
• ¨ Computer skills required with knowledge of Microsoft Office suite.
• ¨ Good written and verbal communication skills required.

JOB KNOWLEDGE/EXPERIENCE:

• ¨ One (1) year experience in a hospital or physician office setting is preferred
• ¨ Previous experience as a medical scribe preferred
• ¨ Demonstrates proficiency in Microsoft Office applications
• ¨ Previous experience with an EMR system preferred
• ¨ Must have excellent customer service and organizational skills
• ¨ Requires reasoning ability and good independent judgment

POSITION RESPONSIBILITIES:

• ¨ Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices
• ¨ Keep track of laboratory tests, medications, and radiology tests ordered by the physician
• ¨ Gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records)
• ¨ Coordinate communication between physicians and staff, make and answer telephone calls
• ¨ Document any consultations the physician makes to a patient’s personal doctor, family members, on-call physician, or other members of the medical community
• ¨ Take vital signs and room patients as needed
• ¨ Accompany provider to hospital to document consults or hospital rounds as needed
• ¨ Provide patients with updates about waits and delays
• ¨ Document all procedures done by the physician, as dictated by the physician
• ¨ Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient
• ¨ Other duties as assigned

LINES OF RESPONSIBILITY:

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Compassion, Accountability, Respect, Excellence through Knowledge and Safety & Social Conscience.